Current medications

Patient #1

• – Alprazolam (Xanax) 0.5 mg/d as needed for agitation (BZ)

Patient #2

• – Methylphenidate-ER (Concerta) 18 mg/d (stimulant)

• – Bupropion-XL(Wellbutrin-XL) 300 mg/d (NDRI)

• – Sertraline (Zoloft) 100 mg/d (SSRI)

• – Zolpidem (Ambien) 10 mg at bedtime (BZRA)

Question

Do patients suffering from unstable, affectively labile, insatiable, frustration-inducing, volatile Cluster B moods respond to psychopharmacology?

Yes

No

Maybe

Attending physician’s mental notes: initial evaluation

Both patients are motivated for treatment and have very similar presentations

Both have initial failures with psychotropics

Patient #1 was subtherapeutic on an antidepressant and he discontinued as it was not helping

• – He has been undertreated

Patient #2 is the opposite and appears to be on many medications

• – Most of which are therapeutic

• – He may have been overtreated

Both stopped some of their medications without consulting their individual prescribers, which is troubling

The MDD symptoms should be easy to treat as they are relatively new

The personality disorder symptoms will increase treatment resistance and likely predispose both patients to frequent depressive relapses

Will need to better delineate adjustment disorders (that are numerous) versus state-dependent, full MDEs as well

There will likely be clear interplay between stress adjustments, personality coping styles, and frank MDD

Question

Which of the following would be your next step for both patients?

Use psychotherapy alone as there are no approved drugs for treating personality traits

Use SSRI/SNRI as they are approved for MDD

Use a mood stabilizing antiepileptic medication as some are approved for bipolar mood stabilization and have some data showing effectiveness in personality disorders where mood lability is problematic

Use an atypical antipsychotic as some are approved for bipolar mood stabilization, depression, agitation, and have some nonregulatory data showing effectiveness in personality disorders, especially for cognitive, perceptual, and aggressivity symptoms

Use buspirone or a beta-blocker as they have some off-label data showing effectiveness in treating anger and irritability

Attending physician’s mental notes: initial evaluation (continued)

Further discussion with the treating psychotherapists is needed to better delineate diagnoses

• – Their depressive spells seem legitimate and sustained for both patients

• – This is felt to be superimposed on top of long-standing Cluster B personality traits

These traits are felt to be further exacerbated by stress and depression

Likely, ongoing psychotherapy will be needed in order to maximize psychopharmacological response and prevent relapses

Using an approved antidepressant makes on-label sense, but the level of mood lability may warrant a mood stabilizing antipsychotic or mood stabilizer, which is not unlike treating a bipolar patient

Further investigation

Is there anything else you would especially like to know about these patients?

What about details concerning the patients’ potential for metabolic disorder?

• Both patients are overweight with centralized abdominal obesity

• Both patients share HTN and elevated lipids

• Discussions with their PCPs suggest these are relatively well controlled with statins and antihypertensives

• Both patients have slightly elevated blood glucose levels suggesting pre-diabetes

• Both patients have family members who developed full metabolic disorder with age